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More has been learned about sleep in the last 60 years than in the past 6000 years Mansoor Ahmed. MD, FACCP, FABSM Medical Director, Cleveland Sleep & Research Center Assistant Professor of Medicine Case Western Reserve University Fellow American Academy of Sleep Medicine .
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60 years than in the past 6000 years
Mansoor Ahmed. MD, FACCP, FABSM
Medical Director, Cleveland Sleep & Research Center
Assistant Professor of Medicine
Case Western Reserve University
Fellow American Academy of Sleep Medicine
History of Sleep Medicine…1953 to PresentFrom Basement To Congress to Wall Street Until 1975, Sleep Medicine was deemed experimental ,1995 Canada followed
4 Mile Stones : 1: REM Sleep 2: PSG 3 : Circadian Biology 4: OSA
responded and 50 were diagnosed to have narcolepsy)
European Development: First Sleep Text Book, Human EEG, Sleep Apnea.
Diabetes, Weight Gain, Hypothyroid
Insomnia and Hypersomnolence
Mood Disorders, ADHD
OSA and …..
Hypertension, A Fib
MI, Stroke, CHF
Opioids & CSA
CFM –Pain & Sleep
Alzheimer's Disease, Stroke
Sleep Disorders : Case Presentation: PTSD
Put your thoughts to sleep,do not let them cast a shadowover the moon of your heart. Let go of thinking.
Sleep is essential for physical, emotional and mental health
Greeks: Hypnos &Thanatos
1929: Human EEG Alpha Waves (Hansberger)
1953: REM Sleep (Asrenski, Klietman and Dement)
1968: Sleep Stages Scoring Rules ( R&K)
1965: OSA Clinical Studies (Gastaut)
1970: Stanford First Sleep Clinic ( Dement)
1982: CPAP (John Remmer ,Sullivan)
Underserved & Under-recognized Discipline
50-60 million American suffer from 80 identified sleep disorders
Sleep and Cardio-Vascular Disorders
51% of CHF patients has underlying sleep-breathing disorder
OSA is an independent risk factor for hypertension.
30-40% patients with hypertension has OSA
Mood Disorders and Sleep, PTSD, ADHD
70% of Patients with mood disorders has sleep pathology
Sleep disturbance& fatigue are hallmark of MS, Parkinson disease, Alzheimer's Disease, Narcolepsy, Sleep Waking Disorders
Challenger Tragedy, >100,000 road accidents annually
Shift Work, Delayed Phase Syndrome
The National Highway Traffic Safety Administration estimates
A: Snoring & Obstructive Sleep Apnea
B: Circadian Rhythm Sleep Problems: Shift Work, Night Owl Syndrome Jet Lag
D: Narcolepsy and other Hypersomnolence Disorders
E: Restless Leg Syndrome
What we are dealing with here, are two gigantic problems for our society – An epidemic of undiagnosed and untreated sleep disorders; and pervasive sleep deprivation with all its consequences for errors, accidents, disability, damages and death“
Sleep and Psychiatry are inherently linked together at every level.. From disease mechanism to clinical Symptoms to outcomes Multiple Psychiatric Pathologies with Multiple Sleep Pathologies
47 Year female, history of depression, anxiety, history noted for childhood trauma, subsequent spousal abuse, alcohol abuse; History of Chronic Fibromyalgia referred by pain specialist for snoring and OSA evaluation :
History of Sleep initiation and Sleep Maintenance Insomnia, uncomfortable sensation in legs, night mares, teetth Clenching frequent nocturnal awakening, non-restorative sleep.,
Wake up tired, severe day-time sleepiness, cataplexy-sleep paralysis
Clinical Evaluations: Sleep Wakefulness history, ENT, PTSD scales
Investigations: Sleep Diary, PSG-MSLT
OSA, Restless Legs Syndrome, Chronic Insomnia
Increased REM frequency
T Young, NEJM 1993; 328:1230-5
Narrow oropharynx but similar narrowing seen in normal Mechanism different in different patients due to factors related to control of breathingOSA worsens over the time Upper Airway Anatomy Plus Control of Breathing
Anatomy: Bony Structure, Soft Tissue, Obesity
Control of Breathing : Chemo responsiveness, Negative pressure
Upper Airway Muscles: Tongue, Palate, Hyoid Bone
Control Of Breathing : Magdy Younes, John Remmer, Jerry Dempsey, SafwanBadr, Neil Cherniack,
AtulMalhotra, David White , S Javaheri
Effort gradually increases
Night Symptoms: Loud Snoring, Choking, Frequent awakening, Restless Sleep
Daytime tiredness/Sleepiness, Mood-Memory, Concentration
Consequences: Increased BP, Stroke, Diabetes,
Mechanism of Sleep-Apnea and Sleep Hpoventilation
1) Narrow Upper Airway: Obesity, E.N.T problems, Dysmorphism
2) Control of Breathing: Hormones, Cardiac Dysfunction
Apnea Hypopnea Hypoventilation
PO2 PCO2 Negative Intra-Thoracic Pressure
Arousal, Sympathetic Activation , Systemic-Pulmonary Vasoconst
Signs & Symptoms: Sleepiness, Hypertension- LV dysfunction ,
STOP: Yes to 2 or More
STOP BANG: Yes to 3 or more
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation
0 = would never dose; 1 = slight chance of dozing2 = moderate chance of dozing; 3 = high chance of dozing
SituationChance of Dozing (0-3)
Sitting and readingWatching TVSitting, inactive in a public place (eg, a theater or a meeting)As a passenger in a car for an hour without a breakLying down to rest in the afternoon when circumstances permitSitting and talking to someoneSitting quietly after a lunch without alcoholIn a car, while stopped for a few minutes in traffic
Mitler and Miller. Behav Med. 1996;21:171.
Type 1 – Attended in-lab polysomnography
Type 2 – Comprehensive portable polysomnography
– Minimum of 7 channels including EEG, EOG, chin EMG, ECG/HR, airflow, respiratory effort and O2 saturation
Type 3 – Modified portable sleep apnea testing
– Minimum of 4 channels including ECG/HR, O2 saturation and at least 2 channels of respiratory movement or respiratory movement and airflow
Type 4 – Continuous single or dual bioparameters – For example, airflow and/or O2 saturation
CPAP is the most effective but compliance is the key issue
SCN plays a pivotal role in maintaining wakefulness by generating an “alerting signal” that opposes the homeostatic sleep drive.
During the evening, the alerting signal is thought to be attenuated, in part via elevation in melatonin concentration during the night, allowing sleep to occur
Borbély, A., & Achermann, P. (1999). Sleep Homeostasis and Models of Sleep Regulation Journal of Biological Rhythms, 14 (6), 559-570 DOI:
6 Distinct CRSDs are recognized in the ICSD-2:
A symptom of either difficulty in falling asleep maintaining sleep or just sense of having insufficientsleep, causing an uncomfortable subjective experience, in some ways analogous to chronic pain
30% general population experience insomnia
Most of the patients patients with mood disorders has sleep pathology
Psychiatric disorders are the single largest cause of chronic insomnia in sleep-clinic population
Percentage of Patients
*Sleep disturbance “some” or “a good bit” of the time for four weeks.
†Sleep disturbance “most” or “all” of the time for four weeks.
MI = myocardial infarction; CHF = congestive heart failure; BPH = benign prostatic hypertrophy.
Katz DA, McHorney CA. Arch Intern Med. 1998;158:1099-1107.
Hypnotics can be used on long term basis in Primary Insomnia
Exercise, CBT, Sleep Hygiene
Insomnia, Sleep Apnea, Restless Legs, Shift Work
3. Determine Circadian Phase
Diet/light snack , exercise, hot bath, relaxing techniques, Bed timing and sleep timing, prescription medications
What Not to do
Clock watching, thinking about next day issues, worrying about sleep, Coffee/Smoking/Alcohol Catching-up over the week-ends
Mitler and Miller. Behav Med. 1996;21:171.
Number of REM Periods
Recorded in All 5 Naps
13.4 ± 4
REM periods/5 naps
3.0 ± 2.7
Control N=17Narcolepsy N=57
Adapted from Mitler et al. Psychiatr Clin North Am. 1987;10:593.
Excessive daytime sleepiness
Parkes. Sleep. 1994;17:S93; Mitler M et al. Sleep. 1994;17:352;
Daly and Yoss. Narcolepsy. In: Handbook of clinical Neurology. Vol.15.1994;15:836; Bassetti and Aldrich. Neurol Clin. 1996;14:545; Mamelak et al. Sleep. 1986;9:285.
Key RLS Diagnostic Criteria
Other Diagnostic Considerations
Nazima and Shazeena